Understanding Functional Capacity Evaluation Billing for California Workers’ Compensation

Functional Capacity Evaluations (FCE) are crucial in the workers' compensation process, helping determine an injured worker's ability to return to work. Proper billing for FCEs is essential for ensuring timely and accurate reimbursement. This blog delves into the specifics of coding, regulations, NCCI edits, and changes brought about by legislative updates.

How to Code Functional Capacity Evaluations

Functional Capacity Evaluations are typically billed using CPT code 97750, which is defined as “Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes.” This code captures the time-intensive nature of FCEs, with billing increments based on 15-minute intervals.

Key Coding Points:

• Use CPT code 97750 for FCEs.
• Ensure documentation includes a detailed report of the evaluation.
• Bill in 15-minute increments, accurately reflecting the time spent on the evaluation.
• Billing Limitations: 97750 is billable up to 2 hours only. Any time spent beyond 2 hours is not payable under this code.

Strategies for Maximizing Reimbursement:

Combination of Codes: To potentially increase reimbursement, consider using a combination of codes. For example, other physical therapy or occupational therapy codes may be applicable for additional services provided during the FCE session. Ensure all billed services are documented and justified.

Regulations Governing FCE Billing:

The California Division of Workers’ Compensation (DWC) Medical Billing and Payment Guide provides detailed regulations for billing FCEs. Key points include:

Documentation: Providers must maintain comprehensive records of the evaluation, including specific tests performed and outcomes.

Timeliness: Bills must be submitted within the timeframes specified by the DWC to avoid denials or delays.

Compliance: Ensure all billing practices comply with the latest DWC guidelines and updates.

NCCI Edits and Their Impact

The National Correct Coding Initiative (NCCI) edits play a crucial role in preventing improper billing practices. These edits ensure that codes billed together are appropriate and not duplicative. For FCE billing:

• Check NCCI Edits: Before submission, verify that the FCE code 97750 is not billed inappropriately with other codes that might be considered part of the evaluation.
• Bundling: Be aware of bundling issues where certain services might be considered part of the FCE and not separately billable.

Medically Unlikely Edits (MUEs) for CPT 97750:

Medically Unlikely Edits (MUEs) are applied to ensure that the number of units billed for a procedure is within the expected range of medical necessity. For CPT 97750:

Billing Limit: MUE for 97750 limits billing to a maximum of 8 units (or 2 hours) per patient per day. Exceeding this limit can lead to denials​​.

Exceptions: In rare cases where more than 8 units are medically necessary, providers may need to obtain a signed agreement with the employer or insurer’s claims administrator to ensure reimbursement. Modifiers such as 76 (repeat procedure by same physician), 77 (repeat procedure by another physician), and 59 (distinct procedural service) can sometimes be used to justify additional units​.

Changes in FCE Billing Pre-2014 and Post-SB Updates

Prior to 2014, FCE billing practices were less standardized, often leading to inconsistencies in reimbursement. The introduction of Senate Bill (SB) changes brought significant updates:

• Pre-2014: FCEs were often coded using a variety of CPT codes, leading to confusion and inconsistent payments.
• Post-2014: The implementation of standardized coding practices with the exclusive use of CPT code 97750 helped streamline the billing process and improve reimbursement consistency.

Notable SB Updates:

• SB 863: Enhanced medical review processes and implemented new fee schedules, impacting how FCEs are billed and reimbursed.
• Documentation Requirements: Strengthened requirements for detailed reporting to support billed services.

The Role of Medrina Technology Management

At Medrina Technology Management, we specialize in providing comprehensive workers' compensation billing and collections services. Our expertise ensures that Functional Capacity Evaluations are billed accurately and in compliance with the latest regulations. By partnering with us, healthcare providers can benefit from:

Expert Coding and Billing: Our team stays updated with the latest coding practices and regulatory changes, ensuring accurate and timely billing for FCEs.

Regulatory Compliance: We ensure all billing practices adhere to the California Division of Workers’ Compensation guidelines and NCCI edits.

Maximized Reimbursement: Through strategic use of coding combinations and thorough documentation, we help providers maximize their reimbursement potential.

Our commitment to excellence in medical billing and collections helps providers focus on delivering quality care while we handle the complexities of workers' compensation billing.

Conclusion

Billing for Functional Capacity Evaluations in California Workers’ Compensation requires careful attention to coding, regulatory compliance, and adherence to NCCI edits. The transition to standardized practices post-2014, driven by legislative changes, has improved the accuracy and consistency of FCE billing. By following the outlined guidelines, understanding the limitations on billing time, and exploring potential strategies for maximizing reimbursement, providers can ensure proper compensation for these critical evaluations. Partnering with Medrina Technology Management can further streamline this process, offering expert support and ensuring optimal billing practices.